A Personalized Approach to Maintaining Brain Drainage: A Case Series with a Technical Note.

Background/

Objectives

The percutaneous insertion of an external ventricular drain (EVD) is a common neurosurgical procedure that is crucial in managing acute brain injuries because of the drain's role in monitoring intracranial pressure and draining cerebrospinal fluid. The primary indication is acute hydrocephalus, which often results from subarachnoid hemorrhage, intracranial hemorrhage, traumatic brain injury, stroke, or infection. Standard EVD placement targets the frontal horn of the lateral ventricle. However, complications such as hemorrhage, infection, and catheter occlusion frequently arise, with occlusion rates ranging from 19% to 47%. Occlusion can lead to increased intracranial pressure, necessitating interventions such as saline flushes or fibrinolytic drug administration. The placement of an EVD is a very specific choice that must be tailored to the individual patient, often in scenarios in which multiple interpretations of the data are possible: the question of which patient is eligible for EVD placement may be subjective. Intraventricular fibrinolysis (IVF) with urokinase-type plasminogen activator (uPA) or tissue-type plasminogen activator is used with the aim of lysing intraventricular clots and preventing EVD occlusion. Despite numerous studies, conclusive evidence on their efficacy is lacking. The CLEAR III trial confirmed the safety of IVF but showed uncertain benefits in neurological outcomes. Given the limited literature on uPA, this study evaluates its intrathecal administration for the prevention of EVD occlusion. Not all therapies are appropriate for all patients, and customizing strategies is often the right way to get the best result.

Methods

This retrospective study analyzed 20 patients with EVDs receiving intrathecal uPA. The patients had a mean age of 56.4 years, with 95% presenting with hydrocephalus and 80% presenting with intraventricular hemorrhage. uPA dosages varied (25,000-100,000 IU), with an average of 3.9 doses per patient.

Results

IVF effectively maintained EVD patency in 95% of cases. One patient experienced asymptomatic bleeding, while four (20%) developed post-treatment infections, the development of which was potentially influenced by the prolonged duration of EVD retention (>21 days). Analysis of Graeb scores showed faster clot resolution with early uPA administration. A higher initial Graeb score correlated with increased total uPA load but not with mortality or discharge outcomes. Although infection rates were slightly higher than in CLEAR III, multiple confounding factors, including duration of EVD retention and bilateral placement, were present.

Conclusions

This study supports the feasibility and safety of intrathecal uPA administration for management of EVD occlusion in certain contexts. The appropriate choice in the context of 'personalized medicine' must necessarily consider the risk-benefit ratio.